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Price and Effectiveness: Nasonex vs Nasacort Or Flonase

posted on March 15, 2016

My wife gets seasonal allergy in the spring. Her doctor prescribed a nasal spray Mometasone (brand name Nasonex) last year. She asked for a refill. The doctor’s office sent the refill prescription electronically to the pharmacy.

How much will it cost? Our insurance plan shows the drug is covered, and it’s on the preferred list. It will be $239 for one bottle from a retail pharmacy or $641 for three bottles by mail order.

Before we meet the deductible on our high deductible health plan, we will be paying 100% of this price.

Because it’s still a brand-name drug with no generic, if we don’t go through insurance, the discount program GoodRx doesn’t give much of a discount either.

Meanwhile, similar drugs Nasacort and Flonase went OTC in recent years. Their prices are much lower. Nasacort is $18 for one bottle at Amazon, $35 for a 3-pack at Costco. Flonase is $21 for one bottle at Amazon, $54 for a 3-pack at Costco.

Hmm, under $20 for OTC versus over $200 for prescription, is the prescription drug Nasonex that much better? I asked my wife if she wanted to send a message to her doctor and ask if the OTC drugs would be just as effective. She said she’d be a fool if she didn’t try the OTC drugs first. Whatever works the best will be the one she will use regardless the price.

This is another example of how a high deductible health plan helps lower the cost for everyone. If we only had to pay a $25 copay under a PPO plan, we wouldn’t have considered the lower cost OTC drugs. We would actually feel good about having it covered by insurance. However, mindlessly paying the higher cost through insurance would unnecessarily raise the cost for everyone, including eventually ourselves through higher premiums.

Price and effectiveness aren’t necessarily directly related. Considering that the two OTC drugs were prescription drugs only a few years ago, we fully expect them to work just as well at 1/10th the cost. Stop the mindless spending on health care.

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At the time the doctor gave the prescription, the other two drugs already went OTC. The doctor did not say “if your co-pay is high get these OTC drugs.” It could be just operating under the old habit of never considering the price because the co-pay masks any price difference. As more and more people get on high deductible plans, doctors need to get up to speed on considering both price and effectiveness when prescribing.

We often blast financial salesmen/women for steering people to expensive investments. We should also expose doctors for prescribing expensive treatment if they get a kickback in doing so.

Physicians cannot (legally) get kickbacks such as the one you are referring to. The “old days” of pharmaceutical companies giving money, vacations, and other bribes to physicians are long gone. Now they can’t even give out pens.

We don’t get a kick-back. I have yet to receive a check for any prescription I have ever written.
I do sometimes get some mediocre lunches where I have to sit and listen to a drug rep tell me about their crappy drug.

There seems to be a disconnect between the gifts the doctors posting in this thread are receiving and the gifts that the doctors in my area are receiving.

To anyone still reading this thread, go out to Yelp and look for Doctors in your area within a particular specialty, say dermatology. Take the first five doctors from the yelp result and plug their names, one at a time, into the propublica doctor lookup site here: https://projects.propublica.org/docdollars/

On my search, all but one of the doctors I selected from random are receiving payments from $650 to $3000, mostly for food and beverage. That ain’t mediocre – that Michelin-starred restaurant food!

I just checked myself.
I received $1055 worth of stuff(overwhelmingly food, apparently 1 medical textbook though I don’t recall this happening) from 8/2013-12/2014(17 months).
That was from 21 different companies.
If I counted correctly I was detailed on 43 different drugs as a result.
The highest amount related to any particular drug was a total of $158. It is not immediately clear to me in looking at the site how many meals that covered. However I can see that it was for victoza and I can tell you that those reps were in the office frequently. In exchange for a dozen or more mediocre meals I zero patients that I can think of on Victoza. One of their direct competitors(similar drug in same drug class that works essentially the same) gave me $0 worth of mediocre food. I have 2 patients on it that I can think of as it seems like a better drug.
Of the 43 different drugs I was detailed on and had a mediocre lunch while being detailed, I have never written, not a single time, for 13 of them.
My average payment for the 77 different times I was apparently given mediocre food was $12.69. I am not sure what Michelin-starred restaurant you have been to , but that doesn’t buy the appetizer. But it does get some lukewarm fried chicken and soggy green beans.
The prices seem inflated. I don’t see a single claim for <$10 but I cannot think of a single meal that I would have paid $10 for.

The scenario described in the post is both a pro and a con. Yes, consumers will be more exposed to the high costs of care and may take actions to mitigate the cost, putting downward market pressure on medical costs. On the other hand, consumers will be rationing their health to save money. That could lead to devastating health consequences for the consumer if they choose poorly.

Doctor here. There is no kickback, certainly not anymore. We generally have no idea how expensive the drugs we prescribe are, partly for ethical reasons, and partly because there are so many variables that go into how much a particular medication costs a particular patient at a particular pharmacy, there’s no way to keep it all straight. That being said, pharmaceutical companies use marketing strategies on us, and the beauty of marketing is that it works on people who are unaware that they are being marketed to.

That $2000 your doctor received was worth maybe $1000 in actuality and was received on behalf of 50+ different drugs, including direct competitors. Frequently for drugs your doctor has never written for, ever, not once.

Harry,
I suggest she try the generic prescription Flonase (Fluticasone Propionate). Where I live, it is less expensive than the OTC Flonase if I use LowestMed.com. After trying both, I find that I like the sprayer on the generic bottle better and it seems to work just as well.

I love your newsletters. I found your site in a search for how to do the darn backdoor IRA in TurboTax and I’ve been a faithful reader ever since. 🙂 Keep up the good work!

Harry,
enjoy your columns.
This happens a lot. ran into this with Doryx (acne medication) for son . insurance company will only cover for generics or older formulations of the drug. So pharma companies game it by offering coupons to slightly different variations e.g. extended release. Dermatologist has to approve you for coupon which will whack off 100s of dollars from price. These dermatologists seem to be very popular and you can locate them by word of mouth or internet searches.

wanted to complete editing my previous comment.
the gaming comes in because the pre-discount price is applied to deductible. so after 3 refills your deductible is up and you only pay the copay price but insurance company is forced to pay for the highly inflated brand name price since that is what the dermatologist prescribed. So I am sure dermatologists benefit in some form.

I would refuse to aid and abet in this scheme on principle. It feels like insurance fraud — claiming a higher loss than the actual cost. I heard it’s illegal to give coupons to Medicare patients. It should be made illegal for private insurance as well.

Epipen is another drug that costs hundreds of dollars and preys on parents who have no choice but to pay whatever is asked. They generally have a coupon to knock of $100 dollars as well. If you don’t have a High Deductible plan, they may give you a reasonable copay of say $50, $100, or so.

My understanding is that EpiPen is much cheaper in countries like Canada. Also, they expire within a year and parents are asked to buy multiple boxes (one for home, one for school, etc.). So essentially following this advice, we as parents are expected to allocate well over $1000 annually because we have a kid with a severe allergy.

Here is my recommendation. Usually, I suffer a lot due to allergies during this time. This year I am trying out Neilmed Sinus Rinse Allergy And Sinus Regular Premixed Sachets which is about $15 in Amazon and a lot cheaper at Costco for a 2 pack one. Natural and no side effects. I did not have any issue this year though living in Texas. I would recommend this to everybody.

Second that.
I have used the nasal rinse therapy/method for a few years now and it has worked for me. Used to have terrible allergy issues and suffered every spring and fall for weeks at a time. However, this nasal rinse method works for me only if my nose is not already clogged up and I do the rinse on a daily basis. I missed out on doing that for a few weeks when on travel and now Im all clogged up and chemical warfare (mucinex, zyrtec, claritin, flonase.. whatever) is the only way out for some relief despite the fact that all the remedies have some sort of undesirable side effect. Once my nasal passages are clear, back to nasal rinse again.

Another MD chiming in:
Very unlikely that kickbacks of any kind are involved; and as someone who has worked a couple of years in outpatient settings I’ll mention that most patients want the convenience of Walgreens at their low co-payment. Attempts to educate people to shop for low cost generics is often received poorly, sometimes with suspicion, and it always takes time away from other discussion. That said, if a patient broached the topic I was always happy to suggest the least expensive good alternative I was aware of and I can probably count on two thumbs the number of times I have prescribed a non-generic medicine for an Internal Medicine practice.

Second, Harry’s approach was reasonable and rational though my preference for personal supply of generic allergy and asthma medicines (yes, me too) as someone with high deductible insurance is to buy through the internet at international pharmacies that sell drugs made in the UK, New Zealand or Israel. I avoid India due to an unfortunate counterfeit supply in that country, and I avoid Turkey due to lack of information.

Fluticasone is a fantastic medicine, although there is not much to differentiate one anti-inflammatory corticosteroid from another other than the amount required for equivalent effect (the potency,) and those differences are usually accounted for in the unit or dose packaging. or in the prescription. A patient may prefer or better handle a particular delivery system over another (particularly asthma medications) but so far as the medicines go — find the least expensive.

These are 3 different drugs and as we all know different people react differently. Flonase gives me horrible sinus headaches and mild relief from allergies., Nasacort gives very mild relief. Not enough for me. Rhinocort (now over the counter) used to work pretty well but recently caused weird vision problems. Nasonex is the only one that provides good relief. That in combination with Allegra 24 hr tablets. But it really stinks that Nasonex is so darned expensive with a High Deductible health plan. Obama’s health care changes have really screwed up my coverage.

Keep in mind though that the amounts are per year, are broken down by categories of “food” and speaking engagements, and the food is typically offered to the entire office staff. So a doctor who received say $3000 in food for a year received about $60 per week. This sounds like a modest lunch once a week for an office staff equivalent.

There is now a generic mometesone nasal spray equivalent to Nasonex available in the US, but it’s still pretty expensive in the US. (About $75-100 if you use GoodRX various places in the US). No insurance plan available to me covers even the generic – even if you have nasal polyps as I do,

HOWEVER, it only costs about CDN$15 in Canada (for more doses – I asked a Canadian Pharmacist last summer and he was totally amazed what we pay for the stuff!), and in Australia you can get it over the counter as Sensease (and I think a different branding as well), for about $10US.

I asked several European friends to check the prices and they were in the range of 10 to 20 Euros as I recall.

The US is still subsidizing the rest of the world as far as I can tell.

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